Texas
The grant’s primary purpose was to increase participant options for controlling personal care services. The grant had one major goal: to implement a Service Responsibility Option (SRO) in the Medicaid State Plan Primary Home Care program (offered under the Personal Care option) to complement the existing Consumer Directed Services option in which participants manage an individual budget and services. The SRO is an agency-with-choice self-direction model.
The grant was awarded to the Texas Department of Aging and Disability Services (DADS).
Role of Key Partners -
The Texas Health and Human Services Commission, the University of Texas-Austin Center for Disability Studies, the Texas Geriatric Education Center, the Texas Geriatric Association, Centers for Independent Living, Area Agencies on Aging, advocacy organizations, a provider association, and individual providers served on the SRO Task Force.
The Task Force functioned as a work group whose activities included selecting the sites for a pilot demonstration, developing outreach materials and a training curriculum, developing the protocol for the new option, and participating in the evaluation and sustainability planning. When the grant ended, the SRO Task Force was subsumed under the Consumer Direction Workgroup (described below).
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The Health and Human Services Commission—the state Medicaid Agency—helped to develop the infrastructure for the SRO by providing policy guidance through the legislatively mandated Consumer Direction Workgroup (operating since 1999). The Commission also developed and submitted a State Plan Amendment to cover Support Consultation (the State’s term for counseling/support brokering) in the Personal Care Option, a key element in sustaining SRO.
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The Texas Geriatric Association provided guidance on outreach strategies.
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Two Centers for Independent Living in the pilot sites worked with the grant’s contractor to conduct SRO orientation activities.
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Advocacy organizations, such as ADAPT and Advocacy Inc, conducted outreach through local offices.
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The Texas Association for Home Care invited grant staff to speak about the SRO at their annual meeting and sent out updates about the SRO.
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The Area Agencies on Aging participated in outreach activities.
Major Accomplishments and Outcomes -
The grant’s contractor designed and implemented an SRO pilot demonstration in two regions: the Texas panhandle and San Antonio. DADS local and regional staff enrolled 29 individuals receiving care from 18 home health agencies as participants in the demonstration. Because only 114 Primary Home Care participants statewide use the Consumer Directed Services option, enrolling 29 participants in the SRO pilot in just two areas of the State demonstrated significant interest in the new option.
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The grant’s contractor designed outreach materials to inform participants about available self–direction options, including the new SRO option. Grant staff distributed more than 5,000 DVDs and 7,000 brochures. The grant contractor also developed orientation and training materials, including an SRO training curriculum, a toolkit, and a self-training DVD for participants.
In addition, the contractor developed a case manager handbook and a provider operational protocol, both describing their respective roles in and participant use of the SRO. The contractor trained 24 participants, 722 DADS case managers, Area Agencies on Aging staff, 105 providers, and 43 staff in managed care organizations statewide.
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Two Centers for Independent Living mailed a brochure about SRO to all Primary Home Care participants in the two pilot areas, and conducted in-person SRO orientation with individuals who had selected the option.
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Grant staff fielded and analyzed 43 in-person Participant Experience Surveys. Of these, 21 participants were using the SRO, 5 were using the Consumer Directed Services option, and 17 participants were using agency-directed care. Evaluation of the survey data supported the need for the SRO, especially for those who had prior negative experience with attendants from agencies under the traditional service delivery system.
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The SRO Task Force assessed SRO effectiveness and made necessary adjustments in the service protocol to prepare for statewide expansion.
Enduring Systems Change -
Information provided through early grant activities informed the State’s self-direction policy, and in September 2007, the State enacted legislation requiring the SRO to be available in all Texas Medicaid waiver programs, State Plan services, and managed care programs. Later grant activities developed the regulatory infrastructure for SRO as well as a comprehensive range of outreach, education, and training materials.
For example, to implement the SRO statewide, DADS staff drafted Texas Administrative Code rules, Chapter 43. The proposed rules were approved by the Medical Care Advisory Committee on May 8, 2008, and approved by the DADS Council on June 18, 2008. DADS regional and local services staff developed policies and procedures outlining the responsibilities of case managers in facilitating access to and the use of the SRO.
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DADS staff and the Health and Human Services Commission developed a State Plan Amendment (SPA) to add consultation support as a State Plan service, a requirement of the SRO. The SPA was submitted to CMS on March 30, 2008, and is currently on hold until another State Plan Amendment regarding self-directed services has been approved.
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The Health and Human Services Commission has committed to offering the SRO in the State’s managed care program and in the Personal Care Services for Children program (available under the Medicaid State Plan Personal Care option). In addition, training on self-direction—including the SRO—is now a standard part of the Texas Association for Home Care quarterly administrators’ training.
Key Challenges -
Provider agencies initially resisted the SRO because of concerns about potential liability issues related to the injury of the provider agencies’ employees under the management of individuals using the SRO. To counter provider fears, grant partners developed a quality framework protocol to ensure that participants understand their role and responsibility in reducing risks, and to allow some agency oversight in accordance with participants’ wishes.
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Because initial enrollment in the SRO was low, grant staff changed their outreach strategy, targeting information sessions to existing gathering places, such as senior centers, rather than relying solely on the DADS regional and local staff to conduct outreach.
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Self-direction requires case mangers to view the individuals they serve differently from how they are used to viewing them. Because this can be difficult, case manager resistance to SRO was prevalent initially. Some case managers found it difficult to make the paradigm shift needed to support participant-directed services. Training sessions were modified to encourage case managers to discuss their concerns and learn from one another.
Continuing Challenges
The State recently added the Consumer Directed Services option to the Intellectual and Developmental Disability waivers and is encountering resistance to the idea that participants in these waivers can direct their own services. The State continues to offer additional education to shift negative and/or skeptical attitudes toward self-direction among service coordinators, case managers, and program staff (e.g., state staff recently completed a series of town hall meetings across the State, which featured a consumer panel).
Lessons Learned and Recommendations -
Successful outreach efforts for a new service delivery option require that individuals and families be informed about the full range of service options early in the referral process. Also, to reduce the potential for provider resistance to a new participant-directed service option, it is important to frame it as one in a continuum of options for managing services, including the traditional agency option. This approach not only can help to bolster provider support but it can also promote informed choice by participants based on their preferences.
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To assist case managers in making the shift from working in the traditional service delivery system to one that allows participants to direct their services, states first need to understand their fears and concerns and then address them systematically using research findings and the experiences of other states.
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To ensure the likelihood that systems change initiatives will be sustained, states should link them to ongoing, high-profile initiatives such as (in Texas) the expansion of Medicaid managed care, the new Integrated Care Management waiver quality assurance/quality improvement initiative, the Aging and Disability Resource Centers, or other grants.
Key Products
Outreach and Educational Materials
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The contractor developed It’s Your Choice, an outreach brochure on self-direction for participants, and produced a video—It’s your Choice: Deciding How to Manage Personal Assistance Services—which describes self-direction for participants.
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The contractor created CD and DVD formats of an SRO orientation for participants, which highlights the roles and responsibilities of the participant, the provider agency, and DADS regional case managers. It also provides an overview of the SRO toolkit.
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The contractor produced The Service Responsibility Option: Consumer Orientation and Training curriculum and a toolkit for SRO participants. The toolkit includes information about (1) backup planning; (2) participant skill building; (3) interviewing and hiring; (4) selecting and training an attendant; (5) supervising, coaching, and evaluating the attendant; (6) dismissing the attendant; and (7) educating the home care provider agency to streamline the attendant hiring process.
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The contractor produced training materials for case managers and providers: The Service Responsibility Option: Provider Protocol and the Service Responsibility Option Case Manager Manual. The training focused on new agency rules for the Consumer Directed Services option, introduced the SRO, explained the philosophy behind participant choice, and discussed how to offer participants the three service management options—agency-directed, participant-directed, and the SRO.
Technical Materials
The grant’s contractor and agency staff developed an SRO protocol for use by case managers and providers implementing the pilot demonstration in two regions.
Reports
The grant’s contractor produced a report, Legal Responsibility under the SRO, which is an analysis of liability issues regarding the SRO.
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